Duration of CCU/PACU Normal units in effect when MRMC Recommended /ER/ which drip is MRMC standard Primary short-term Half- infusion is Nursing Monitoring Cardiac cath Cardiac/surgical Medical Cardiac Drug Use ordered concentration side effects life Onset Peak stopped Parameters usual dose maximum dose lab stepdown telemetry telemetry Notes Amiodarone Treatment/prophylaxis of mg/min 1.8 mg/ml provided as hypotension (Usually within 1st 15-100 Prompt, Days Days Continous EKG monitoring . load:150 mg over 10 min doses > 2100 mg/day May initiate and May initiate and maintain Maintain fixed May initiate and *run through filter set (Cordarone) VT/VF, supraventricular 450 mg/250 ml dextrose few hours, rate related), days usually BP monitoring: q 15 min x4, then (max rate of 30 mg/min) associated with increased maintain up to 1 mg/min infusion up to 1 maintain up to *in glass bottle for infusion arrythmia,cardiac arrest or 900 mg/500 ml arrythmia ,ARDS within hr q 30 min x2,then q 1hr x2, then q maintenance: 1 mg/min x 6 hypotension mg/min in stable 1 mg/min greater than 2 hr dextrose glass bottle 4hr hr then 0.5 mg/min. Rate patient * conc greater than 2 mg/ml may be adjusted, but > must be run through central 2100 mg/day associated line with increased hypotension *monitor QT interval and report prolongation to physician Fenoldopam Short term control (up to mcg/kg/min 10 mg/250 ml which is 40 cardiac arrhythmia, 5 min 5-15 min 15-20 15 min-4 hr Continous EKG monitoring. 0.1 to 1.7 mcg/kg/min. 1.7 mcg/kg/min May initiate, no no no *Monitor serum potassium at (Corlopam) 48 hr) of severe mcg/ml hypotension,hypokalemia min,another BP monitoring: q 15 min x4, then doses < 0.1 mcg/kg/min maintain and titrate least q 6 hr initially. hypertension text lists 30 q 30 min x2,then q 1hr usually have modest *Maximum recommended min-2 hr) effects, usual infusion is 48 hour recommended starting dose is 0.1 mcg/kg/min and adjust by 0.05 mcg/kg/min- 0.1 mcg/kg/min q 15 min (less frequently as bp goal approached) Diltiazem (Cardizem) temporary control of rapid mg/hr 1 mg/ml arrhythmia, hypotension, CHF 3.4 hr 1-3 min if 2-7 minutes 0.5-10 hr after drip Continous EKG monitoring. bolus: initial: 0.25 mg/kg 15 mg/hr. Some May initiate, May initiate, maintain may initiate and May initiate, *Maximum recommended ventricular rate in atrial started with after bolus turned off BP monitoring: q 15 min x4, then over 2 min. max bolus: physicians use up to 20 maintain, titrate fixed infusion rate, titrate maintain fixed maintain fixed duration is 24 hr. Check with fibrillation or flutter, bolus. q 30 min x2,then q 1hr x2, then q 0.35 mg/kg over 2 min. mg/hr (20 mg/hr up to 15 mg/hr infusion rate up to infusion rate, titrate MD about switching to oral conversion of PSVT to 4hr maintenance: 5-15 mg/hr maximum) 15 mg/hr up to 15 mg/hr formulation after 24 hr-first NSR dose of oral medication usually given before stopping infusion *multiple incompatibilities including heparin and furosemide *prepared as 1:1 drip by adding 125 mg of diltiazem (which is contained in 25 ml of solutioin) to 100 ml of diluent for a total volume of 125 ml and a final concentration of 1 mg/ml DoPAmine hypotension,CHF mcg/kg/min 800 mg/250 ml which is arrhythmia, 2 min 5 min very short after drip Continuous EKG monitoring, . 2-20 mcg/kg/min. up to 50 20 mcg/kg/min unless May initiate, May initiate, maintain no May initiate, *Extravasation requires 3200 mcg/ml hypertension,vasoconstriction, turned off BP monitoring: q 15 min x 4, then mcg/kg/min has been specifically instructed by maintain, titrate fixed infusion rate up to maintain flat infusion treatment. If available, necrosis with extravasation q 30 min x2, then q 1h x2, then q used, but is not physician to go higher. 10 mcg/kg/min,titrate up rate up to 5 phentolamine is the preferred 4hr. Urine recommended Doses up to and beyond to 10 mcg/kg/min mcg/kg/min agent. If unavailable, output. Daily weight For 50 mcg/kg/min have nitroglycerin is used (see note all doses > 10 mcg/kg/min: q 2 hr been used at end of table) peripheral pulse and extremity *note: look alike/sound alike checks. drug with doBUTamine. Check order and IV bag carefully. DoBUTamine short term inotropic mcg/kg/min 500 mg/250 ml which is arrhythmia, hypertension, 2 min 2 min 10 min very short after drip Continuous EKG monitoring, . 2-20 mcg/kg/min. up to 40 20 mcg/kg/min unless May initiate, May initiate, maintain May initiate, May initiate, *note: look alike/sound alike (Dobutrex) support 2000 mcg/ml hypotension, increased HR turned off BP monitoring: q 15 min x 4, then mcg/kg/min has been specifically instructed by maintain, titrate fixed infusion rate up to maintain fixed maintain fixed drug with DoPAmine. Check q 30 min x2, then q 1 hr x2, then q used, but increases physician to go higher. 10 mcg/kg/min,titrate up infusion rate up to infusion rate up to order and IV bag carefully. 4hr. Urine output. Daily weight. potential for toxicity to 10 mcg/kg/min 10 mcg/kg/min 10 mcg/kg/min Eptifibitide (Integrilin) acute coronary syndrome mcg/kg/min 75 mg/100 ml premixed bleeding-usually from invaded 2.5 hr bolus 1 hr 2-4 hr FOR ALL PATIENTS: check 180 mcg/kg bolus x1 over 2 mcg/kg/min for patients May initiate, May initiate,maintain No May initiate and Monitor for bleeding or signs **Note: not a and PCI bottle which is 0.75 mg/ml site or GI or GU sites followed by creatinine clearance and verify 1 min (for acute coronary (with maximum dose of maintain maintain in precath and symptoms of bleeding. vasoactive drip, but Note: Eptifibitide is also infusion dose. (NOTE: CREATININE syndrome) or x2 (for PCI 20 ml/hr of the 0.75 patients or patients Report any bleeding or frequently used in available in a 20 mg/10 ml produces CLEARANCE CALCULATOR with boluses 10 min mg/ml infusion) with not going to cath lab changes in vital signs or status cardiac areas vial that is to be used for immediate AVAILABLE ON BON SECOURS apart;each bolus over 1 creatinine clearance suggestive of bleeding to the bolus only inhibition, INTRANET. CONTRAINDICATED min), then 2 mcg/kg/min greater than or equal to physician immediately. steady state IN DIALYSIS PATIENTS).Monitor (for creatinine clearance 50 ml/min. NOTE: two sizes of bottles reached in 4- patients for signs/symptoms of greater than or equal to 50 1 mcg/kg/min for patients stocked. 2 mg/ml 10 ml vial is 6 hr bleeding. ml/min) or 1 mcg/kg/min (with maximum dose of for bolus. 0.75 mg/ml 100 ml FOR PRECATH PATIENTS AND (for creatinine clearance 10 ml/hr of the 0.75 vial is for infusion PATIENTS NOT GOING TO less than 50 ml/min) mg/ml infusion) with CATH LAB: continuous EKG creatinine clearance monitoring, vital signs and check less than 50 ml/min. of invaded sites and neurochecks q 1 hr x 4,then q 2hr x2, then q 4 hr; heme test all stools;gastroccult all emesis. POSTCATH PATIENTS: per cath lab protocol Epinephrine vasopressor mcg/min 2 mg/250 ml which is 8 anxiety, pallor, palpitations, short rapid short continuous EKG monitoring 1-10 mcg/min 10 mcg/min may initiate, no no no *multiple drug interactions and (Adrenalin) mcg/ml profound vasoconstriction and BP monitoring: q 5 min until maintain, titrate contraindicated drug compromise of renal and gut stable, then q 15 min x 4, then q combinations. blood flow, hypertension 30 min x2, then q 1 hr. Peripheral pulse and extremity checks q 2 hr. urine output. Duration of CCU/PACU Normal units in effect when MRMC Recommended /ER/ which drip is MRMC standard Primary short-term Half- infusion is Nursing Monitoring Cardiac cath Cardiac/surgical Medical Cardiac Drug Use ordered concentration side effects life Onset Peak stopped Parameters usual dose maximum dose lab stepdown telemetry telemetry Notes Esmolol (Brevibloc) SVT, intraoperative and mcg/kg/min 2.5 grams/250 ml which is hypotension, bradycardia, 1-2 min 1-2 min within 30 min continuous EKG monitoring. FOR SVT: load: 500 300 mcg/kg/min for May initiate, no no no *for short term use only* postoperative 10 mcg/ml inflammation of infusion site. BP monitoring: q 15 min x4, then mcg/kg over 1 min, hypertension. 200 maintain, titrate hypertension and/or Beta-blockers, such as esmolol, q 30 min x2, then q 1 hr continuous infusion at 50- mcg/k/gmin for SVT tachycardia may cause arrhythmia, angina, 200 mcg/kg/min (start at MI,death if stopped abruptly. 50 mcg/kg/min. after 4 minutes, may give additional bolus and increase rate by 50 mcg/kg/min. As desired effect is approached, eliminate bolus and titrate in increments of 25-50 mcg/kg/min. May increase titration time from 5 to 10 min. FOR HYPERTENSION: as for SVT, but may require doses up to 300 mcg/kg/min. May also give 80 mg IV over 1 minute followed by 150 mcg/kg/min infusion if needed. titrate as needed. Ibutilide rapid conversion of afib or ordered as 1 mg or less may be given undiluted or ventricular arrhythmias, including 6 hr conversion continuous EKG monitoring while >60 kg: 1 mg over 10 initiate initiate no initiate *While administering, staff (Corvert) aflutter of short duration to diluted in 50 ml of NS or torsades de pointes. (risk usually administering and for 4 hr after minutes. May repeat x1 10 ratio must be 1:1. Patient must sinus rhythm D5W and given as an increases with QTc interval > 440 occurs finishing, or longer if arrythmia min after end of first be placed on lifepack with infusion. MRMC msec, K less than 4, pts on other within 30 occurs or patient has liver infusion if arrhythmia is not multifunction pads attached recommends an infusion, Class Ia or III antiarrythmics-in min, but dysfunction. terminated. If < 60 kg, while receiving and for at least but in either case the dose clinical studies held for 5 t1/2 may occur BP monitoring: q 15 min x 4, then 0.01 mg/kg over 10 min, 4 hr afterward (longer if should be given over 10 prior to giving ibutilide and for 4 up to 90 min q 30 min x 2, then q 1 hr x2, then may repeat x1 10 minutes arrhythmia occurs or liver minutes hr after) q 4 hr after end of first infusion if dysfunction ) arrhythmia is not *watch QT interval for terminated prolongation *risk of torsades de pointes *hypokalemia, hypomagnesia should be corrected prior to administration (electrolyte abnormalities increase risk of arrhythmia) *patients should not receive other Class Ia or Class III antiarrhythmics (quinidine, procainamide, disopyramide, bretylium, amiodarone, sotalol) concominantly with ibutilide or for 4 hours afterward, and these agents should preferably be held for five half-lives prior to administering ibutilide. These agents increase risk of arrhythmia. Isoproterenol atropine-resistant mcg/min tachycardia, hypotension, cardiac 3-7 hr immediate 1-2 hr continous EKG monitoring. atropine resistant 30 mcg/min in advanced initiate,maintain, no no no (Isuprel) hemodynamically ischemia, cardiac arrythmias BP monitoring: q 15 min x4, then bradycardia: 2-20 shock. Administer for 1 titrate significant bradycardia, q 30 min x2, then q 1hr mcg/min, shock:0.5-5 hr or less in septic shock shock, diagnosis of mitral mcg/min up to 30 mcg/min regurgitation, diagnosis of CAD, refractory torsade de pointes, beta- adrenergic blocker poisoning Labetalol (Trandate, hypertension,decrease bp mg/min 500 mg/250 ml which is 2 hypotension (especially postural 5 hrs, 5-20 min with bolus continous EKG monitoring. 0.5-2 mg/min. see previous column initiate, maintain, no no no Normodyne) and symptoms in patients mg/ml orthostatic hypotension), less some administration: 3-6 hr, BP monitoring: q 15 min x4, then recommended to stop titrate with pheochromocytomia likely to cause bradycardia than effects with BP returning to q 30 min x2, then q 1 hr x2, then q infusion when max of 300 other beta-blockers,ventricular may last baseline in 16-18 hr 4 hr. Maintain patient in supine mg is reached or arrhythmia (1%) up to 16 position satisfactory response is hr achieved (and begin oral form), but has been used as continuous infusion in CCU patients at 1-180 mg/hr for up to 9 days Lidocaine treatment or prophylaxis of mg/min 2 grams/250 ml D5W anaphylaxis, cardiac arrest, qrs 1.5-2 hr 45-90 sec 10-20 min after single continuous EKG monitoring usually bolus followed by 4 4 mg/min initiate, maintain initiate, maintain no initiate, maintain Obtain serum levels with use vfib/v tach, status which is 8 mg/ml widening, tremor, after bolus bolus mg/min greater than 24 hours or epilecticus (unlabeled twitching,confusion,nervousness suspected toxicity. Half-life use) increases over time and infusion rate may require decrease Milrinone (Primacor) short term management mcg/kg/min 20 mg/100 ml D5W which arrhythmia, hypotension 1-3 hr 10 min if load continuous EKG monitoring load: 50 mcg/kg over 0.75 mcg/kg/min initiate, maintain initiate, maintain initiate, maintain initiate,maintain *not shown to be safe or of acute decompensated is 200 mcg/ml given BP monitoring: q 15 min x 4, then 10min, then infusion at effective for more than 48 hr heart failure q 30 min x2, then q 1 hr x 2 and 0.375 mcg/kg/min- 0.75 then q 4 hr. daily mcg/kg/min. Decrease weight. Urine output dose with renal dysfunctiion Duration of CCU/PACU Normal units in effect when MRMC Recommended /ER/ which drip is MRMC standard Primary short-term Half- infusion is Nursing Monitoring Cardiac cath Cardiac/surgical Medical Cardiac Drug Use ordered concentration side effects life Onset Peak stopped Parameters usual dose maximum dose lab stepdown telemetry telemetry Notes Nesiritide (Natrecor) treatment of acutely mcg/kg/min 1.5 mg/250 ml which is 6 hypotension 18 min 60 % of 3 hr half of recovery of sbp continuous EKG monitoring 2 mcg/kg bolus over 1 min, 0.03 mcg/kg/min may initiate and may initiate and maintain no may initate and *IV tubing should be primed decompensated chf in pt mcg/ml (but effect of toward baseline after BPmonitoring q 15 min x 4, then q then 0.01 mcg/kg/min. maintain maintain with 25 ml of infusion prior to with dyspnea at rest or pharmaco pcwp reduct d/c is seen with 60 30 min x2, then q 1 hr x 2 and May increase dose as administration of bolus or minimal activity dynamic seen in 15 min. hypotension may then q 4 hr. daily weight. Urine follows: 1 mcg/kg bolus infusion half-life min, 95% last several output followed by increase in rate *use limited to 48 hours longer, seen in 1 hr.following d/c pcwp of 0.005 mcg/kg/min. *hypotension when it occurs and hour,75% of within 10 % of Increases may be made as can be prolonged. hypotensi 3 hr sbp baseline within 2 hr frequently as q 3 hr to max *Concurrent use of other IV on may reduction of 0.03 mcg/kg/min. vasodilators or oral last reached antihypertensives may be several within 15 additive hours min *If hypotension occurs, nesiritide may be restarted once BP stabilized if ordered by physician-infusion rate should be reduced by 30% and no bolus should be given *must run through dedicated line Nitroglycerin (Tridil) Unstable angina, CHF, mcg/min 50 mg/250 ml D5W headache, hypotension, 2-30 min 1-2 min 5-10 min continuus EKG monitoring BP initial: 5-10 mcg/min. doses up to 1000 initiate, titrate, initiate, maintain, titrate no initiate, maintain flat *contraindicated in patients hypertension tachycardia monitoring: q 15 min x4, then q 30 adjusted upward as mcg/min have been used maintain up to 50 mcg/min rate, titrate up to 20 using sildenafil (Viagra), min x2, then q 1 hr x2, then q needed (usually by units of but our maximum is 200 mcg/min vardenafil (Levitra) or taldalafil 4hr.frequent assessment of chest 5-20 mcg/min depending mcg/min without (Cialis) which are erectile pain upon indication and current physician approval dysfunction agents dose). *safe interval between use of sildenafil or vardenafil and nitroglycerin has not been determined. levels at 24 hr after sildenafil are much lower than at peak. *for taldalafil, the interaction is present up to and including 24 hr after taldalafil. At 48 hours, the interaction by most hemodynamic measures was not seen, but some taldalafil patients had a greater drop in blood pressure than placebo patients. Beyond 48 hours interaction is not detectable. nitroprusside hypertensive emergency, mcg/kg/min 100 mg/250 ml D5W hypotension, sweating, EKG 3-4 min 30-60 sec 1-2 min 1-10 min continuous EKG monitoring 0.1-5 mcg/kg/min. see previous column initiate, maintain, only post-carotid surgical no no * contraindicated in patients acute CHF, cardiogenic which is 400 mcg/ml changes, increased ICP, muscle ;continuous BP monitoring: BP absolute max is 10 titrate patient taking Viagra, Levitra or Cialis shock twitching, restlessness, cyanide documentation at least q 5 min til mcg/kg/min which (see nitroglycerin note) toxicity, methemoglobinemia, stable, then q 15 min x4, then q should never be run for *symptoms of cyanide thiocyanate toxicity. Cyanide 30 min x2, then q 1 hr . more than 10 min. best to toxicity are air hunger, bright results from the breakdown of avoid doses > 3 red venous blood, nitroprusside in the body. The mcg/kg/min in pt with nl confusion,restlessness, elimination of cyanide depends renal function and doses > agitation convulsions, upon its conversion to 1 mcg/kg/min in anuric cardiovascular instability thiocyanate; how much cyanide patients b/c thiocyanate metabolic acidisos (ANION may be processed depends upon levels require several days GAP METABOLIC ACIDOSIS the amount of thiosulfate in the to come back from lab. IS ONE OF EARLIEST, MOST body (stores may be depleted in Doses greater than 2 CONSISTENT FINDINGS). chronically or critically ill mcg/kg/min may result in Treatment of cyanide toxicity is patients). Thiocyanate is then cyanide toxicity. d/cing infusion, oxygen and eliminated by the kidney. sodium thiosulfate. Whether cyanide toxicity develops *symptoms of thiocyanate depends upon the rate of toxicity are primarily CNS in nitroprusside infusion (prolonged nature including weakness, infusions or rates greater than 2 tinnitus, agitation, tremor, mcg/kg/min can result in cyanide hallucinations,lethargy. may toxicity) and the amount of also include abdominal pain thiocyanate the patient's body and vomiting. Treatment is contains. Whether thiocyanate hemodialysis. toxicity develops depends upon *Methemoglobinemia is the amount of thiocyanate formed characterized by cyanosis (which depends on the unresponsive to oxygen, nitroprusside infusion rate) and despite normal arterial oxygen the patient's renal function. tension Norepinephrine hypotensive state mcg/min 8 mg/250 ml D5W which anxiety,arrhythmias, chest pain, 1-2 min continuous EKG monitoring, 0.5 to 30 mcg/min. (usual 40 mcg/min initiate, maintain, no no no *Extravasation requires (Levophed) is 32 mcg/ml ischemia, necrosis with continuous BP monitoring: BP 8-12 mcg/min initially, titrate treatment. If available, extravasation documentation at least q 5 min til maintainance usually 2-12 phentolamine is the preferred stable, then q 15 min x4, then q mcg/min. Alternatively may agent. If unavailable, 30 min x2, then q 1 hr . start with 0.5-1 mcg/min, nitroglycerin is used (see note Peripheral pulse and extremity and titrate as needed to 2- at end of table) checks q 2 hr. Urine output 12 mcg/min) . Phenylephrine hypotension mcg/min 10 mg/250 ml D5W which bradycardia,hypertension,tremors 1-2 min 1-2 min 15 min continuous EKG monitoring, 40-180 mcg/min. usually 200 mcg/min initiate,maintain,titr only post-carotid surgical no no *Extravasation requires (Neosynephrine) is 40 mcg/ml , ventricular continuous BP monitoring: begin at 100-180 mcg/min, ate patient treatment. If available, tachycardia,ventricular documentation of BP q 5 min til unitl bp stabilized, then phentolamine is the preferred extrasystoles, extravasation stable, then q 15 min x4, then q decrease to 40-60 agent. If unavailable, causes necrosis 30 min x2, then q 1 hr . mcg/min nitroglycerin is used (see note Peripheral pulse and extremity at end of table) checks q 2 hr. Duration of CCU/PACU Normal units in effect when MRMC Recommended /ER/ which drip is MRMC standard Primary short-term Half- infusion is Nursing Monitoring Cardiac cath Cardiac/surgical Medical Cardiac Drug Use ordered concentration side effects life Onset Peak stopped Parameters usual dose maximum dose lab stepdown telemetry telemetry Notes Procainamide ventricular tachycardia mg/min 4 grams/500 ml D5W or 2 hypotension, PR interval 2.5-8 hr continuous EKG monitoring may give up to 20 mg/min 6 mg/min maintenance initiate, maintain initiate,maintain no initiate, maintain (Pronestyl) when lidocaine grams/250 ml D5W which prolongation, QRS widening, QT BP monitoring: q 15 min x4, then in loading dose phase (up contraindicated or has not is 8 mg/ml interval prolongation, ventricular q 30 min x2, then 1 hr x2, then q to maximum of 1 gram). suppressed, wide-complex arrhythmias, blood dyscrasias, 4hr. Keep patient supine Maintenance: 1-4 mg/min tachycardias difficult to lupus like syndrome distinguish from VT **treatment of extravasation for dopamine, norepinephrine, phenylephrin: RNs may initiate phentolamine (Regitine) therapy following dopamine, phenyleprine or norepinephrine infiltration in peripheral IV sites. T The IV is discontinued immediately and phentolamine therapy is initiated within one hour of infilitration (per nursing policy PF726). If phentolamine is unavailable, nitroglycerin ointment may be used. For adults, 1 inch is applied to the afected area and may be repeated q 6-8 hr if ischemia continues or returns.
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